Provider Demographics
NPI:1831709757
Name:PRATT, TAMIKA NICOLE
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:NICOLE
Last Name:PRATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 OLD ORANGE PARK RD APT 141
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-3012
Mailing Address - Country:US
Mailing Address - Phone:904-589-0735
Mailing Address - Fax:
Practice Address - Street 1:141 OLD ORANGE PARK RD APT 141
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-3012
Practice Address - Country:US
Practice Address - Phone:904-589-0735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA390774251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP15722266OtherSTATE OF KENTUCKY